SOCIETY PROCEEDINGS AMERICAN ACADEMY OF PEDIATRICS SYMPOSIUM ON PEDIATRIC SURGERY

HERBERT E. COE, ~.D., Chairman, Seattle The surgery of this period of life is in the highest degree physiologic surgery as distinguished from excision surgery, the surgery of evolution instead of involution, and it requires particularly close attention to the caloric, fluid, and electrolytic demands of growth--all of which concepts are fundamental in the care of children. The idea is commonly current that children's surgery is synonymous with the so called "surgical abdomen"--as typified by a panel discussion in the tentative program for the approaching series of sectional meetings of the American College of Surgeons entitled "Pediatric Surgery (or abdominal surgery in children)". This concept completely disregards the neo-natal surgical emergencies, the surgery of the extra abdominal congenital defects, neuro-surgery, the plastic surgery of accident and scars so characteristic of this irresponsible period of life and the high proportion of children in the surgical practice of the orthopedist and the otolaryngologist. INGUINAL

I{ERNIA

IN INFANTS

WILLIS J. POTTS. Our rather unusual experience with ingllinal hernia in infants at the Children's Memorial Hospital during the past year prompts the writing of this paper. Because the figures are for only one year they are not presented for percentage quotation. During this time 32 infants less than 18 months of age were operated upon for inguinal hernia. Seventeen had simple uncomplicated hernias; five had hernias with associated hydroceles. In ten patients the hernia was incarcerated and could not be reduced before operation. In five of this group the bowel showed various stages of congestion which cleared when the constriction was released. One baby, a premature infant, weighing only 1,6oo gin. evidently had an incarcerated hernia for some time before admission to the hospital. At operation strangulation of the bowel was apparent. The child's condition was very poor. Because the bowel was blue black but seemingly intact; it was decided that the risk of simply replacing the bowel in the abdomen was less than that of resection. The decision was wrong.

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The baby died in two days and at post-mortem examination peritonitis as a result of perforated small intestine was found. Furthermore, in two of the children with incarcerated hernias the testicle was black due to strangulation. Complete atrophy of the testicle has followed in both. This unusually high percentage of incarcerations and associated complications, although not likely to be repeated in any future year, indicates the importance of intelligent handling of the simple but oft recurring problem of hernia in infancy. ,~TIOLOGY: The ~etiology of inguinal hernia in infants is extremely simple. All are indirect and all are -congenital due basically to one factor alone--failure of the processus vaginalis to obliterate itself normally. Persistent cough, constipation, excessive crying and phimosis are merely contributing factors which tend to break open a process ~improperly closed. Variation in degree of obliteration of the processus vaginalis accounts for various degrees of hernia and for the formation of hydrocoels. If the entire processus remains open the hernial sac obviously extends all the way to the testicle. Obliteration of the distal portion usually results in a small hernia with a short sac, whereas obliteration of the proximal portion only may result in the formation of a hydrocele. Segmental obliteration of the processus leads to the development of co-existing hernia and hydrocele. Nothing could be simpler. DIAGNOSIS: T h e diagnosis of inguinal hernia in an infant is easy when the baby is brought in with a bulge in the inguinal region which can be reduced with a gurgle discernible to the palpating finger. It is less simple when the mother says that she has seen a lump in the groin once. Stimulating the baby to cry wilI not bring out the hernia. Palpation of the internal ring with a finger is unsatisfactory and inconclusive. Palpation of the inguinal canal, that is, rolling the tip of the finger transversely across the structures of the cord will, if a hernia is present, impart a sensation of rubbing silk surface together. This manoeuvre is of value but requires considerable experience before one feels confidence in it alone as diagnostic. At times one has to admit that a diagnosis is impossible and further observation will be necessary. A similar problem in diagnosis is posed when a definite hernia is present on one side and the mother thinks that there may be another on the opposite side. If surgery on one side is decided upon it is very wise, if for self protection only, to examine the other side and make a note with the date that at this examination the hernia is unilateral. Not infrequently, if by pure coincidence a hernia appears on the opposite side after operation, the mother blames the physician or the surgeon for overlooking the second hernia. To distinguish a hydrocele from a hernia is theoretically simple

4

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b~dian Jourl, al of Pediatrics

but sometimes impossible. I have been wrong oftener than I am h a p p y to admit. The small, oblong, unchanging in size, not tender, fluctuant, tight-transmitting mass in the cord, or the characteristic collection of fluid _around the testicle is instantly recognizable as a hydrocele. However, when the mother says that the mass in the groin is smaller in the morning and enlarges slightly during the day after the infant stands in its crib or cries, one is suspicious that the mass, although irreducible, is probably a hernia with a small opening. Both hydrocele and hernia m a y be present. Since it is not our policy to operate on hydrocele in infants it is important to distinguish them from hernias. When a differential diagnosis is impossible and subjective symptoms are absent, further observation is in order. A frantic mother brings her b a b y in with a mass in the groin which she says appeared suddenly. The b a b y is screaming whether because of pain in the groin or on general principles is not readily ascertainable. The mother is convinced that the b a b y has an incarcerated hernia about which she has heard reports and the examiner is not sure. The mass is irreducible but transmits light readily. Fluid and air in the intestine will transmit light. Nothing is more disconcerting than to put a needle into such a mass for diagnosis and to withdraw intestinal contents. The impulse to solve the problem quickly with a diagnostic needle should be curbed. Usually a little time spent in soothing the child with a bottle and the mother with an air of confidence is all that is necessary, plus a second examination, to differentiate a suddenly appearing hydrocele from an incarcerated hernia. TREATMENT: Very few hernias will be cured permanently b y the use of a truss. To the latter claim I now subscribe unqualifiedly. A truss will support some hernias fairly well but that is all, I do not believe any truss on the market will cure more than a very occasional hernia and I am inclined to believe that the " c u r e d " hernia is potentially still there and is apt to appear with any sudden strain. The treatment of inguinal hernia in infants, otherwise normal, is surgical regardless of age. The infant who is in poor condition because of congenital variations from normal or because of disease should be treated with a truss, if treatment is necessary, until it is in condition to undergo surgery. Manual reduction of an increased hernia is preferable to surgical. A hernial sac which is friable and oedematous because of constriction is difficult to dissect out and dispose of properly. It often tears. It is more satisfactory to operate in a few days after the cedema has disappeared. An incarcerated hernia can be reduced b y continuous but very gentle pressure while the infant is concentrating on a nipple well reinforced with sugar. If simple pressure fails and there seems to be no urgency for reduction the baby is given a sedative such as nem-

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butal and adhesive tape for traction is applied to the legs. Sufficient weight is attached to raise the baby while only its shoulders and head touch the bed. After an hour or two if this elevation plus some more gentle pressure is ineffective in accomplishing a reduction of the hernia, surgery is indicated at once. Surgical repair of an inguinal hernia is a simple but delicate operation. The technique of repair is as follows; under open mask ether anaesthesia, a small transverse incision is made in the suprapubic crease through the skin over the region of the internal ring. The incision is made in the skin crease rather than along conventional lines because it seals itself more rapidly and is therefore less apt to be contaminated by urine or fceces. Such an incision, made along the lines of cleavage, heals more readily and with less tendency towards keloid formation. That the ultimate scar is scarcely visible is of no practical importance but is a source of pleasure to the mother. The external oblique is exposed and split. The external ring is not cut unless the hernia is very large and the ring has been stretched. In most instances it is possible to isolate the sac without opening the ring. One of the main causes of post-operative swelling of the testicle is too snug closure of the external ring. The fascias and cremasteric muscle fibres over the cord are easily slit longitudinally. The sac comes into view and is drawn up out of its bed disturbing the cord as little as possible. The sac is opened and the interior carefully inspected. Usually the bowel has fallen back into the abdomen. Omentum is not found in the sac in infants. Great care is necessary in dissecting the sac from the structures of the cord. A tear into the neck of the sac makes repair difficult and unsatisfactory. The vas, little larger than a silk thread, is attached intimately to the sac and must be peeled off carefully. The most important step in the operation, it. fact, the sole object of the operation is to ligate the sac high. The internal oblique is retracted outward and the interior of the sac again inspected. The sac is then twisted until the properitoneal fat begins to rotate about the twisted sac, Appearance of this properitoneal fat leaves no doubt that the entire processus is obliterated. The sac is transfixed with silk and doubly ligated. When the sac distal to the ligature is cut and the retractor beneath the internal oblique muscle removed, the stump o~ the sac will be seen to snap up beneath the internal oblique muscle. The structures of the cord are allowed to fall back into their normal position. No repair of the hernial floor is done. The object of the operation--to remove the processus vaginalis which nature failed to obliterate--has been accomplished. Why do more? With a few silk sutures the opening in the external oblique is re-

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Indian Journal o[ Pediatrics

paired. Two or three deep sutures in the fat obliterate the dead space. The skin is closed with interrupted subcuticular No. 6-o silk sutures. Subcuticulalr sutul~es are advantageous because the almost immediate sealing of the skin edges lessens the chances of infection in case of gross contamination. Avoidance of the necessity of removing stitches, while a minor consideration, is desirable in the normal wiggly infant. The dressing consists of a very narrow strip of gauze which covers the hairline incision and is held in place with a strip of waterproof adhesive tape. The child is returned to its crib where it is entirely unrestrained. The usual diaper is put on and the infant is given its regular formula as soon as it wishes. If the mother wishes to hold the baby she is allowed to do so. On the second day following operation the patient is dismissed from the hospital. DlscussIoN.--Since surgery is the only cure (about 99% without recurrence in infants) it seems rather illogical to put off the operation for years especially since the percentage of incarceration is greater during the first six months of life. Although no operation and no general anmsthesia is without some danger, a herniotomy carries an extremely small risk. Against the minimaI risk of operation is balanced the anxiety of the mother, the constant bother of a truss, and the danger of incarceration with consequent strangulation of the bowel or loss of a testicle. Besides these negative advantages there is an occasional unexpected reward following a herniotomy. In the small group of patients referred to above and operated upon last year, there were three mothers who voluntarily reported that herniotomy had relieved their children of colic and irritability. I hasten to add that herniotomy is not a suggested cure of colic. As a by-product it is very acceptable. URINARY INCONTINENCE; ITS SURGICAL SIGNIFICANCE: THOMAS H. LANMAN. A very high percent of cases of persistent or recurring urinary infections are the result of an obstructive lesion, usually congenital, somewhere in the urinary tract. No matter how efficientlythe urinary, infection can be brought under control by modern methods, if there is an obstructive lesion present, the infection will inevitably recur. This was well shown by autopsy figures some years ago. A high percent (about 5 ~ percent) of young children dying of pyelonephritis showed some mechanical obstructive lesion which might have been amenable to surgery, had its presence been recognized in time. By far the most important causes are obstructive lesions that are present at birth. These are particularly dangerous in that during

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the first few months of life the infant is not supposed to have urinary control, and unless there is careful observation by the mother or physician, certain symptoms may pass as being due to the normal, but untrained infant. A second group of causes includes those whose symptoms appear at a later age and it is of the utmost importance that should a previously trained young child develop symptoms of incontinence, the cause be most carefully searched for. The most insidious, the most dangerous and the most frequently overlooked cause of incontinence during infancy is some obstructive lesion at the bladder outlet. It is more commonly found in boys and the most frequent lesions are congenital obstructive valves in the posterior urethra. Uretero~gele.--This obstructive lesion usually results in repeated attacks of urinary infection, but the ureteroccele may become of sufficient size to actually obstruct the bladder outlet and, by so doing, give rise to the additional symptom of dribbling fl'o.m the overdistended bladder. Here again, it is of the utmost importance that the obstructive lesion be recognized early, as it is readily remedied by surgery with complete relief of symptoms unless, as a result of long-standing obstruction, there has been irreversible damage to the kidneys. In this group of cases, it is particularly significant that some have come for treatment with the usual story of recurring attacks of pyuria and also, in the more advanced cases, have given the history that the child was normally trained at the usual time, but subsequently began to develop symptoms of urinary incontinence which were the result of the overdistended bladder with obstruction at its outlet. Tumor.--New growth of the bladder is relatively rare in this age group, but it carries an exceedingly grave prognosis. In our small series of bladder tumors almost all have been rhabdomyosarcomata. Urinary incontinence has been striking. In those children below the age of two, it was overlooked because it was not recognized as the dribbling of an obstructed bladder and, in some cases, the symptom appeared in later years of childhood when there had been a considerable period of time with normal bladder control. A cystogram, especially one in the lateral view, usually shows a characteristic filling defect in the bladder; an irregular one in tumor, and a rather smooth, rounded shadow in ureteroccele. Some of the rarer conditions are illustrated by the following:

Foreign Body.--An eight-year-old girl had previous normal development up to the age of four, and at that time had normal bladder control. For the next two years she had symptoms of incontinence, but it was two years later that an X-ray was taken and showed that there was a foreign body in the bladder. A hair pin had apparently been inserted into the bladder about the age of 4 and had eroded through to the anterior vaginal wall. The main thing here is to again

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Indian Journal o] Pediatrics

call attention to the fact that in a child who has developed normal control and then becomes incontinent, a most careful study is warranted. Another case of incontinence was caused by a stone encysted in the remants of the urachus. This was a boy of nine who, up until the age of seven, had apparently normal urinary control. He had no symptoms of urinary infection and for months was treated as a problem child. The calcified lesion in the urachal cyst hung down within the bladder itself and, presumably, caused the symptoms which, properly speaking, were more those of urgency with incontinence, rather than true incontinence. A plain X-ray film gave an immediate clue which resulted in further investigation and had this simple step been taken some months sooner, a great deal of unnecessary delay and annoyance to the family might have been prevented. Removal of the stone resulted in complete cure. Ectopic Ureter.mThere are an increasing number of cases of ectopic ureter coming to our attention. These are more frequent in the female and the ectopic ureter, which is usually one of a double ureter on that side, empties into the urethra distal to the bladder sphincter. It is obvious that the urine which this ureter excretes from that part of the kidneys which it drains, cannot be controlled because this ureter empties digtal to the bladder outlet. We made the mistake of treating a patient of this sort for a number of months as a "problem child", and in the cases we have seen since this have been the common history. Fortunately, the last two types of anomalies mentioned do not, as a rule, lead to any serious impairment or infection of the kidneys and are, therefore, not as urgent as some of the other types mentioned. It is, however, very embarrassing to attempt to treat over a long period of time by psychiatric methods a child who has a lesion such as an ectopic ureter which by its very nature precludes any voluntary control over the excreted urine. The intravenous pyelogram is simple to obtain and will usually give reliable information in establishing the diagnosis of ectopic ureter. I shall speak of exstrophy o] the bladder, which is an obvious anomaly and with obvious reasons for incontinence, only to say that with our present technic we can offer good assurance, not only of urinary control, but of minimal retrograde infection of the kidneys when the ureters have been transplanted into the sigrnoid. In over 5~ cases, we have had no deaths following transplantation. Intravenous pyelograms, as long as I5-16 years after the transplantation, show gratifyingly little evidence of retrograde infection. Not in all cases, of course, but in the great majority. We believe this operation is best done between the ages of 2 and 5 years. The child is then enough to co-operate more intelligently in acquiring control of the rectum and he is not yet of school age. In our series, there is little,

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if any, evidence to make us believe that postponing the operation for two to three years after birth carries any appreciable danger of retrograde kidney infection, as a result of the exposed ureteral openings in the extrophied bladder. Certainly. it is reasonable to assume that transplanting the ureters into the sigmoid moves them into an area fully as contaminated as was their location before transplantation. As pediatricians, it is well to remember that the problem of the extrophied bladder in the male is very much complicated by the associated epispadias, repair of which, even at best, leaves much to be desired from the cosmetic and functional point of view. The psychological effect on the male of urinating in the sitting down position ptus the external appearance of the genitals is a very real problem. In the female this does not present any difficulty. In both sexes, assurance of good urinary control can be given, but in the male this is by no means the entire solution of the problem. There is another very distressing type of urinary incontinence, usually associated with rectal incontinence. In this age group it is largely the result of spina bifida with meningomyeloaele. These patients present a most distressing situation, but in a few cases we have had moderate success by transplanting the ureters to a blind lower sigmoid loop, the distal end of which is close to the rectum and is permanently closed; the proximal end being brought out through the abdominal wall on one side of the abdomen and this opening emptied at regular intervals by the use of a catheter. The open end of the sigrnoid, just above this blind loop used as a bladder, is also brought out through the abdominal wall on the other side and the fceces are taken care of by a colostomy bag. These methods alleviate to a considerable deg.ree, the very distressing situation, but it is too soon to estimate as yet, how great a degree of retrograde infection may take place. This brings me to a discussion of the question of spina bifuia As is well known, evidence of faulty development in the lumbo-sacral spine is an extremdy common incidental finding when X-ray films that include the lower spine are taken. ~Roughly, about one-third of all the cases taken at our clinic show some developmental anomaly, usually incomplete fusion of the spinous process of one or more vertebrm. In i,ooo cases of spina bifida at this clinic, 91 or roughly lO% were classified as spina bifida occulta which demanded further study because of symptoms, usually bladder-symptoms. Of these 91 cases about 25% gave enough on history or physical examination to warrant the assumption that this bony defect was associated with some nerve disturbance which resulted in the symptoms of urinary incontinence. Exploration of the spinal cord was down. The exploration of these cases showed in a very large percent of cases that there was a definite lesion, usually some tumor formation, the removal

occulta.

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India~,z, Jo,v~rnal o/ Pediatrics

of which offered relief of the bladder symptoms. Associated with this type of case are those of definite intraspinal tumors. It is mentioned here and emphasized that not only must careful urologic examination be made on children presenting the symptoms of urinary incontinence, but also a very careful neurologic examination, in appropriate cases. INTESTINAL PERFORATION COMPLICATING TYPHOID FEVER IN CHILDREN:

JEsus LOZOYA, S. The diagnosis of peritonitis by intestinal perforation in cases of typhoid fever was made according to the following pattern: i. A patient with a history of a febrile disease of many days' duration (minimum 7 days, maximum 53 days) becomes severely ill in the last few days (3-4 days prior to admission). We only had four cases of perforation that actually reached the hospital alive after 8, Io, II and 15 days respectively, and they all died. 2. Agglutination reactions were positive in the blood for Types O. and H. of E. typhosa, the titre varying between I x xoo and I • 500 (2 were positive at a low tire; 3 were negative; and in 4 we could not obtain blood samples). 3- There is intense abdominal pain, marked rigiditT--especially in the right iliac fossa--together with foecaI vomiting and gastrointestinal peristalsis; constipation follows a period of diarrh
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I L Almost 60% of the cases have had ihtestinal h~emorrhages and diarrhoea prior to the onset of the picture of perforation. The diagnosis of peritonitis due to nlpture of the g~[1 bladder from typhoid fever is made when in a patient with this disease, a clinical picture of slowly progressive peritonitis is found. Especially is this so, when this condition is compared with one produced by perforation of the intestines. The pain in perforated gall bladder is less intense, ~ocalized to the right hypochondriac region with definite rigidity in this area appearing early. In addition, there is a moderate leukocytosis with relative neutrophilia and a positive agglutination test confirms the diagnosis. Marked abdominal distension and lack of pneumoperitemn are seen even if the X-ray is taken after the patient has been sitting for ten minutes. A picture of a more or less complete occlusion with a great amount of free peritoneal fluid is added to the above findings. Parecentesis abdominis gives a purulent, yellow-greenish fluid, resembling urine sometimes, in which the laboratory easily finds bile pigments; with a typhoid acute cholecytisis the clinical picture is similar to the above, with pain, rigidity and tenderness but no bile can be isolated from the fluid in the abdominal cavity. We stress the point that in a patient with typhoid fever in whom signs of moderate peritonitis are present, the diagnosis of perforated gall bladder has to be kept in mind; in this way all early operation can be life saving. Operations, Pre and Post Operative Care.--The following technic is used in all our cases of a perforated intestine: Drainage of the peritoneal cavity with aspiration of as much pus and fcecal matter as possible, without breaking too many adhesions. After that, a simple suturing of the perforation with catgut is done in most instances. In four, intestinal resection with entero-lateral anastomosis was performed when there were several perforations or in the case of just one perforation with extensive surrounding necrosis. Recently, we have been practising WITZEL'S technic of enterostomy when we are unable to reduce distension with ABBOTT'S or LEVlN'S tube; if the distension can be controlled with tubes we just close the perforation and in this way the patient's problem is solved. Pre and post-operatively sulfadiazine is given subcutaneously in dosage of 0-2o gin. per kg. body weight daily and in fractional doses every 6 to 8 hours. We keep the patients in protein and fluid balance with blood, plasma and gluco~ salines, given 5~ c.c./kg, of blood or plasma daily in accordance witu the hematocrit count and the specific gravity of the urine, but above all, considering the clinical aspect of the patient. The upper respiratory infections, complicating the operation, are treated with penicillin. Patients are denied any oral feedings for three to five days receiving amino-acids intravenously. Gastric and rectal intubation are discontinued when the distension subsides. (A rectal tube is inserted up to the cecum; when possible, guided by the surgeon at operation. 5

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Indian Journal o] Pediatrics

into the ileum through the ileo-cecal valve; for this purpose a long LEVlN'S tube is used). With technic of operation previously described, we have bad 9 survivals in 21 patients with perforation of the intestines: approximately a 43% incidence of cure. With~these methods our statistics are constantly improving and in time our mortality rate should decrease. Amongst other things it must be borne in mind that the cases that terminated fatally came to the hospital in extremis with perforations of many days' duration. In fact, those who did survive had perperforations of less than three days and it is our opinion that the excellent pre and post-operative care contributed greatly to the success obtained. The operative procedures may be summarized as follows:-I. Use every method to combat distension. 2. Avoid reinfection of the peritoneum by closing the perforation, draining it by the WlTZ~L method or with resection and primary laterolateral intestinal anastomosis. 3- Drainage of the peritoneum. 4. Treatment of the infection with all the available means. 5. Supporting the general condition of the patient as normally as possible. In connection with rupture of the gall bladder we have already described the technic. Prognosis can be guided in all cases by the following considerations : I. General Condition. (a) Intense toxic and infectious states. (b) Marked malnutrition. (c) Signs of cardiovascular weakness. 2. Peritoneal picture, more than three days. 3. WBC: Leukopenia under 5,00o; relative neutrophilia and appearance of young forms (myelocytes). All of these patients are malnourished before and during illness and have had enemas and purgative. A great number have had diarrhoea and intestinal haemorrhages. Twenty-one were under I I years of age, a fact that is contrary to the opinion that a perforation in typhoid fever is more common in adolescents. It is pertinent to say that the hospital accepts only patients that are under 15 years of age. Conclusion. I. Intestinal perforation due to typhoid fever is frequent among children (7.22% of all the cases of typhoid). 2. Perforations of the intestines and rupture of the gall bladder in typhoid fever must always be operated. 3- In order to improve the statistics, good pre and post-operative

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care is essential, along with expert surgical technic which must provide drainage of the peritoneum, avoidance of reinfection and of abdominal distensiom 4. Prognosis is in direct ratio to early operation. 5. Malnutrition, intense toxicity and infection with marked leukOpenia, combined with a diagnosis of intestinal perforation or rupture of the gall bladder in typhoid fever, make the prognosis a farm one, ~